Pachymeningeal disease: a systematic review and metanalysis.

BACKGROUND: Pachymeningeal disease (PMD) is a newly recognized pattern of brain metastasis (BrM) failure that specifically occurs following surgery with adjuvant stereotactic radiosurgery (SRS) and has unique prognostic implications relative to leptomeningeal disease (LMD). Here, we report its prevalence, prognostic implications, and associated risk factors. METHODS: A literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses on PUBMED and Cochrane from January 2000 to June 2023. RESULTS: We identified 12 studies that included a total of 3992 BrM patients, 659 (16.5%) of whom developed meningeal disease (MD) following surgery plus adjuvant SRS, including either PMD or LMD. The mean prevalence of MD across studies was 20.9% (7.9-38.0%), with PMD accounting for 54.6% of this prevalence and LMD comprising the remaining 45.4%. Mean of the median overall survivals following diagnosis of PMD and LMD was 10.6 months and 3.7 months p = 0.007, respectively, a significant difference. Only 2 risk factors for PMD were reported in ≥ 2 studies and also identified as statistically significant per our meta-analysis: infratentorial location and controlled systemic disease status. CONCLUSION: While PMD has a superior prognosis to LMD, it is nevertheless a critical oncologic event associated with significant mortality and remains poorly recognized. PMD is predominantly observed in patients with controlled systemic disease status and infratentorial location. Future treatment strategies should focus on reducing surgical seeding and sterilizing surgical cavities.

Dermatofibrosarcoma protuberans of the upper eyelid treated with surface mould high-dose-rate brachytherapy.

Dermatofibrosarcoma protuberans (DFSP) is a rare spindle cell tumor, comprising less than 0.1% of all malignant neoplasms. The trunk is the most commonly affected area, followed by the extremities and the head and neck. Of the latter cases, involvement of the periorbital area has been infrequently reported. Surgery is the cornerstone of treatment but is associated with a high rate of recurrence if margins remain close or positive. This rate has been shown to be considerably decreased by the use of adjuvant radiotherapy. However, most reported cases utilize external beam radiation therapy (EBRT ) in the treatment of DFSP, including those with primary periorbital locations. We report a case of a 40-year-old male, presenting with a small nodule on the right upper eyelid, diagnosed as DFSP with positive margins post-surgery and treated with adjuvant customized surface mould high-dose-rate (HDR) brachytherapy in a low-resource setting.

Hypofractionated radiotherapy in postmastectomy locally advanced breast cancer: an interim report on acute toxicities and dosimetry.

Background: There is a growing interest in the use of hypofractionation in the setting of post-mastectomy radiation therapy (PMRT). Here, we present an interim report on the acute toxicities and the dosimetry of a 15-day hypofractionated regimen. Materials and methods: Patients aged 18-75 years who underwent mastectomy and had pathological stage IIB-IIIC or any clinical stage who had received neoadjuvant chemotherapy were treated with PMRT at a dose of 43.5 Gy in 15 fractions. Acute toxicities were scored using Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results: Between September 2020 and September 2021, 92 patients were enrolled in the study. Majority experienced grade 1 dermatitis during the course of treatment. Skin toxicities peaked two weeks after PMRT in which 57 patients (62%) had grade 2 dermatitis and 6 patients (7%) had grade 3 dermatitis. Most resolved one month after treatment, with all resolving at three months. Grade 2 fatigue occurred in 4 patients (4%). There were no grade 3 fatigue or pneumonitis of any grade. The average V95% for the chest wall, axilla, and supraclavicular fossa were 91.5%, 99.3%, and 97.5%, respectively. Average ipsilateral lung V17 was 43.6%, while the mean heart dose averaged at 3.46 Gy. Conclusion: This interim report showed that hypofractionated PMRT is associated with a low incidence of clinically significant acute toxicities. With the use of the 3-dimensional conformal radiotherapy technique and volume-based planning, adequate target volume coverage and acceptable heart doses were achieved, although with a slightly higher ipsilateral lung dose.

Rate of pachymeningeal failure following adjuvant WBRT vs SRS in patients with brain metastases.

Background: Stereotactic radiosurgery (SRS) has supplanted whole brain radiotherapy (WBRT) as standard-of-care adjuvant treatment following surgery for brain metastasis (BrM). Concomitant with the adoption of adjuvant SRS, a new pattern of failure termed "Pachymeningeal failure" (PMF) has emerged. Methods: We reviewed a prospective registry of 264 BrM patients; 145 and 119 were treated adjuvantly with WBRT and SRS, respectively. The Cox proportional hazards model was used to identify variables correlating to outcomes. Outcomes were calculated using the cumulative incidence (CI) method. Univariate (UVA) and multivariate analyses (MVA) were done to identify factors associated with PMF. Results: CI of PMF was 2 % and 18 % at 12 months, and 2 % and 23 % at 24 months for WRBT and SRS, respectively (p < 0.001). The CI of classic leptomeningeal disease (LMD) was 3 % and 4 % at 12 months, and 6 % and 6 % at 24 months for WBRT and SRS, respectively (P = 0.67). On UVA, adjuvant SRS [HR 9.75 (3.43-27.68) (P < 0.001)]; preoperative dural contact (PDC) [HR 6.78 (1.64-28.10) (P = 0.008)]; GPA score [HR 1.64 (1.11-2.42) (P = 0.012)]; and lung EGFR/ALK status [HR 3.11 (1.02-9.45) (P = 0.045)]; were associated with PMF risk. On MVA, adjuvant SRS [HR 8.15 (2.69-24.7) (P < 0.001)]; and PDC [HR 6.28 (1.51-26.1) (P = 0.012)] remained associated with PMF. Conclusions: Preoperative dural contact and adjuvant SRS instead of adjuvant WBRT were associated with an increased risk of PMF. Strategies to improve pachymeningeal radiation coverage to sterilize at risk pachymeninges should be investigated.

Factors predictive of parametrial boost in patients with cervical cancer treated with definitive chemoradiation.

OBJECTIVE: The aim of this study is to identify demographic, clinical, and treatment-related characteristics associated with the prescription of parametrial boost (PMB) in cervical cancer patients undergoing definitive chemoradiation. MATERIALS/METHODS: A retrospective chart review of 132 non-metastatic cervical cancer patients treated with definitive chemoradiation from May 2017 to December 2019 was performed. Demographic, clinical, and treatment characteristics were obtained and compared between those who received PMB and those who did not. Clinical outcomes (pelvic recurrence, tumor persistence, distant metastases, and median survival time) were also gathered and compared. Statistical software was used for analysis, with a p < 0.05 considered statistically significant. RESULTS: Of the 132 patients included in the analysis, 74 (56%) received PMB of 10 Gy in five daily fractions and 58 (44%) did not. Patients who received PMB were more likely to have pelvic sidewall invasion at the time of diagnosis (OR 4.053, 95% CI 1.163-14.13, p < 0.05) and received more cycles of concurrent chemotherapy during whole pelvis irradiation (OR 2.149, 95% CI 1.370-3.371, p < 0.05). At a median follow-up of 24 months, there was no statistically significant difference in the crude rates of pelvic recurrence, tumor persistence, distant metastasis, and median survival between the two groups. CONCLUSION: Presence of pelvic sidewall invasion at diagnosis and increased number of chemotherapy cycles were predictive of administering PMB after whole pelvis irradiation. There was no significant difference in treatment outcomes for those with and without PMB.

Assessment of the prevalence of pain, adequacy of pain management and influencing factors in patients undergoing radiotherapy.

Pain is prevalent among patients with cancer who are being treated with radiotherapy. However, the prevalence of pain varies across regions, and pain management is affected by several factors. This cross-sectional study aims to determine the prevalence of pain, assess the adequacy of pain management and identify factors affecting pain in patients undergoing radiotherapy. A total of 94 patients were included in the study. The prevalence of pain was determined through the Brief Pain Inventory tool, while the adequacy of pain management was assessed through the Pain Management Index. Demographic, clinical and treatment-related factors were obtained and analysed for association with the presence of pain and the adequacy of pain management. Of the 94 patients, 59 (62.8%) experienced pain while 35 (47.2%) did not. The mean pain intensity score of patients was 3.6 (standard deviation: 2.3). Most patients (67.8%) experienced mild pain with low pain interference (67.8%) on daily functions. Of the 59 patients who experienced pain, 34 (57.6%) had inadequate pain relief while 25 (42.2%) had adequate pain control. Being admitted at the hospital during radiotherapy was significantly associated with adequate pain relief. Use of analgesic was also significantly associated with pain management, with a higher rate of weak and strong opioid use in those with adequately treated pain. In this single-institution study, the prevalence of pain was high. Pain management was inadequate in more than half of the patients experiencing pain. A disparity in the prescription of analgesics, particularly opioids, was observed. Patients with inadequate pain management were less likely to receive opioids, which likely reflects the presence of several barriers that limit its access to patients.